McMaster Model of Family Functioning: adattamento alla realtà italiana, implicazioni cliniche e di ricerca

Il presente lavoro comincia con una descrizione dettagliata del “McMaster Model of Family Functionig” (MMFF), modello che al suo interno integra una teoria multidimensionale sul funzionamento familiare, diversi strumenti di auto ed etero valutazione e chiare indicazioni terapeutiche racchiuse all’interno della “Problem Centered System Therapy of the Family” (PCSTF). Grazie alla sua completezza il Modello fornisce ai clinici metodi coerenti, pratici ed empiricamente validi per valutare e trattare le famiglie, essi inoltre, sono stati formulati in modo da essere adattabili a differenti setting clinici e di ricerca, applicabili ad un’ampia gamma di problematiche e verificabili empiricamente. Obiettivo finale della presente ricerca è stato quello di porre le basi per l’esportazione del MMFF in Italia e poter quindi procedere alla sua applicazione in ambito clinico. La ricerca è cominciata alla Brown University con la traduzione dall’inglese all’italiano del Family Assessment Device (FAD), uno degli strumenti di autovalutazione compresi nel MMFF, ed è in seguito continuata con la validazione del suddetto strumento in un campione di 317 soggetti appartenenti alla popolazione generale italiana. Il FAD si è dimostrato uno strumento valido ed affidabile, in grado quindi di fornire valutazioni stabili e coerenti anche nella sua versione italiana. Il passo successivo è stato caratterizzato dalla somministrazione di FAD, Symptom Questionnaire (SQ) e delle Psychological Well-Being scales (PWB) a 289 soggetti reclutati nella popolazione generale. In accordo con il modello bipsicosociale che vede l’ambiente familiare come il più immediato gruppo di influenza psicosociale dello stato di benessere o malessere dell’individuo, i nostri dati confermano una stretta relazione tra scarso funzionamento familiare, spesso espresso attraverso difficoltà di comunicazione, di problem solving e scarso coinvolgimento affettivo e distress psicologico esperito con sintomi depressivi, ansiogeni ed ostilità. I nostri dati sottoliano inoltre come un funzionamento familiare positivo sia altamente correlato ad elevati livelli di benessere psicologico. Obiettivo della parte finale del lavoro ed anche il più importante, è stato quello di esplorare l’efficacia della Problem Centered Systems Therapy of the Family nella gestione della perdita di efficacia degli antidepressivi nel trattamento della depressione ricorrente. 20 soggetti con diagnosi di depressione maggiore ricorrente secondo il DSM-IV sono stati randomizzati a due diverse condizioni di trattamento: 1) aumento del dosaggio dell’antidepressivo e clinical management, oppure 2) mantenimento dello stesso dosaggio di antidepressivo e PCSTF. I dati di questo studio mettono in evidenza come, nel breve termine, PCSTF e farmacoterapia sono ugualmente efficaci nel ridurre la sintomatologia depressiva. Diversamente, ad un follow-up di 12 mesi, la PCSTF si è dimostrata altamente superiore all’aumento del farmaco ner prevenire le ricadute. Nel gruppo sottoposto all’aumento del farmaco infatti ben 6 soggetti su 7 ricadono entro l’anno. Nel gruppo assegnato a terapia familiare invece solo 1 soggetto su 7 ricade. Questi risultati sono in linea con i dati della letteratura che sottolineano l’elevata probabilità di una seconda ricaduta dopo l’aumento dell’antidepressivo all’interno di una farmacoterapia di mantenimento e suggeriscono l’efficacia dell’utilizzo di strategie psicoterapiche nella prevenzione della ricaduta in pazienti con depressione ricorrente.

Parameters and algorithms to evaluate cardiac mechanics by conductance catheter

This work is structured as follows: In Section 1 we discuss the clinical problem of heart failure. In particular, we present the phenomenon known as ventricular mechanical dyssynchrony: its impact on cardiac function, the therapy for its treatment and the methods for its quantification. Specifically, we describe the conductance catheter and its use for the measurement of dyssynchrony. At the end of the Section 1, we propose a new set of indexes to quantify the dyssynchrony that are studied and validated thereafter. In Section 2 we describe the studies carried out in this work: we report the experimental protocols, we present and discuss the results obtained. Finally, we report the overall conclusions drawn from this work and we try to envisage future works and possible clinical applications of our results. Ancillary studies that were carried out during this work mainly to investigate several aspects of cardiac resynchronization therapy (CRT) are mentioned in Appendix. -------- Ventricular mechanical dyssynchrony plays a regulating role already in normal physiology but is especially important in pathological conditions, such as hypertrophy, ischemia, infarction, or heart failure (Chapter 1,2.). Several prospective randomized controlled trials supported the clinical efficacy and safety of cardiac resynchronization therapy (CRT) in patients with moderate or severe heart failure and ventricular dyssynchrony. CRT resynchronizes ventricular contraction by simultaneous pacing of both left and right ventricle (biventricular pacing) (Chapter 1.). Currently, the conductance catheter method has been used extensively to assess global systolic and diastolic ventricular function and, more recently, the ability of this instrument to pick-up multiple segmental volume signals has been used to quantify mechanical ventricular dyssynchrony. Specifically, novel indexes based on volume signals acquired with the conductance catheter were introduced to quantify dyssynchrony (Chapter 3,4.). Present work was aimed to describe the characteristics of the conductancevolume signals, to investigate the performance of the indexes of ventricular dyssynchrony described in literature and to introduce and validate improved dyssynchrony indexes. Morevoer, using the conductance catheter method and the new indexes, the clinical problem of the ventricular pacing site optimization was addressed and the measurement protocol to adopt for hemodynamic tests on cardiac pacing was investigated. In accordance to the aims of the work, in addition to the classical time-domain parameters, a new set of indexes has been extracted, based on coherent averaging procedure and on spectral and cross-spectral analysis (Chapter 4.). Our analyses were carried out on patients with indications for electrophysiologic study or device implantation (Chapter 5.). For the first time, besides patients with heart failure, indexes of mechanical dyssynchrony based on conductance catheter were extracted and studied in a population of patients with preserved ventricular function, providing information on the normal range of such a kind of values. By performing a frequency domain analysis and by applying an optimized coherent averaging procedure (Chapter 6.a.), we were able to describe some characteristics of the conductance-volume signals (Chapter 6.b.). We unmasked the presence of considerable beat-to-beat variations in dyssynchrony that seemed more frequent in patients with ventricular dysfunction and to play a role in discriminating patients. These non-recurrent mechanical ventricular non-uniformities are probably the expression of the substantial beat-to-beat hemodynamic variations, often associated with heart failure and due to cardiopulmonary interaction and conduction disturbances. We investigated how the coherent averaging procedure may affect or refine the conductance based indexes; in addition, we proposed and tested a new set of indexes which quantify the non-periodic components of the volume signals. Using the new set of indexes we studied the acute effects of the CRT and the right ventricular pacing, in patients with heart failure and patients with preserved ventricular function. In the overall population we observed a correlation between the hemodynamic changes induced by the pacing and the indexes of dyssynchrony, and this may have practical implications for hemodynamic-guided device implantation. The optimal ventricular pacing site for patients with conventional indications for pacing remains controversial. The majority of them do not meet current clinical indications for CRT pacing. Thus, we carried out an analysis to compare the impact of several ventricular pacing sites on global and regional ventricular function and dyssynchrony (Chapter 6.c.). We observed that right ventricular pacing worsens cardiac function in patients with and without ventricular dysfunction unless the pacing site is optimized. CRT preserves left ventricular function in patients with normal ejection fraction and improves function in patients with poor ejection fraction despite no clinical indication for CRT. Moreover, the analysis of the results obtained using new indexes of regional dyssynchrony, suggests that pacing site may influence overall global ventricular function depending on its relative effects on regional function and synchrony. Another clinical problem that has been investigated in this work is the optimal right ventricular lead location for CRT (Chapter 6.d.). Similarly to the previous analysis, using novel parameters describing local synchrony and efficiency, we tested the hypothesis and we demonstrated that biventricular pacing with alternative right ventricular pacing sites produces acute improvement of ventricular systolic function and improves mechanical synchrony when compared to standard right ventricular pacing. Although no specific right ventricular location was shown to be superior during CRT, the right ventricular pacing site that produced the optimal acute hemodynamic response varied between patients. Acute hemodynamic effects of cardiac pacing are conventionally evaluated after stabilization episodes. The applied duration of stabilization periods in most cardiac pacing studies varied considerably. With an ad hoc protocol (Chapter 6.e.) and indexes of mechanical dyssynchrony derived by conductance catheter we demonstrated that the usage of stabilization periods during evaluation of cardiac pacing may mask early changes in systolic and diastolic intra-ventricular dyssynchrony. In fact, at the onset of ventricular pacing, the main dyssynchrony and ventricular performance changes occur within a 10s time span, initiated by the changes in ventricular mechanical dyssynchrony induced by aberrant conduction and followed by a partial or even complete recovery. It was already demonstrated in normal animals that ventricular mechanical dyssynchrony may act as a physiologic modulator of cardiac performance together with heart rate, contractile state, preload and afterload. The present observation, which shows the compensatory mechanism of mechanical dyssynchrony, suggests that ventricular dyssynchrony may be regarded as an intrinsic cardiac property, with baseline dyssynchrony at increased level in heart failure patients. To make available an independent system for cardiac output estimation, in order to confirm the results obtained with conductance volume method, we developed and validated a novel technique to apply the Modelflow method (a method that derives an aortic flow waveform from arterial pressure by simulation of a non-linear three-element aortic input impedance model, Wesseling et al. 1993) to the left ventricular pressure signal, instead of the arterial pressure used in the classical approach (Chapter 7.). The results confirmed that in patients without valve abnormalities, undergoing conductance catheter evaluations, the continuous monitoring of cardiac output using the intra-ventricular pressure signal is reliable. Thus, cardiac output can be monitored quantitatively and continuously with a simple and low-cost method. During this work, additional studies were carried out to investigate several areas of uncertainty of CRT. The results of these studies are briefly presented in Appendix: the long-term survival in patients treated with CRT in clinical practice, the effects of CRT in patients with mild symptoms of heart failure and in very old patients, the limited thoracotomy as a second choice alternative to transvenous implant for CRT delivery, the evolution and prognostic significance of diastolic filling pattern in CRT, the selection of candidates to CRT with echocardiographic criteria and the prediction of response to the therapy.

Le capacità relazionali negli infermieri: un'indagine esplorativa negli spedali civili di Brescia

Nelle attuali organizzazioni sanitarie non è raro trovare operatori sanitari i quali ritengono che la relazione con il paziente consista nell'avere adeguate competenze tecniche inerenti la professione e nell'applicarle con attenzione e diligenza. Peraltro si tende ad invocare il “fattore umano”, ma si lamenta poi che l’operatore si rapporti col paziente in modo asettico e spersonalizzato. Da un punto di vista scientifico il termine “relazione” in psicologia si riferisce essenzialmente ai significati impliciti e quasi sempre non consapevoli veicolati da qualunque relazione: dipende pertanto dalla struttura psichica dei due interlocutori investendo in particolare la sfera dell’affettività e procede per processi comunicativi che travalicano il linguaggio verbale e con esso le intenzioni razionali e coscienti. La relazione interpersonale quindi rientra nel più ampio quadro dei processi di comunicazione: sono questi o meglio i relativi veicoli comunicazionali, che ci dicono della qualità delle relazioni e non viceversa e cioè che i processi comunicazionali vengano regolati in funzione della relazione che si vuole avere (Imbasciati, Margiotta, 2005). Molti studi in materia hanno dimostrato come, oltre alle competenze tecnicamente caratterizzanti la figura dell’infermiere, altre competenze, di natura squisitamente relazionale, giochino un ruolo fondamentale nel processo di ospedalizzazione e nella massimizzazione dell’aderenza al trattamento da parte del paziente, la cui non osservanza è spesso causa di fallimenti terapeutici e origine di aumentati costi sanitari e sociali. Questo aspetto è però spesso messo in discussione a favore di un maggiore accento sugli aspetti tecnico professionali. Da un “modello delle competenze” inteso tecnicisticamente prende origine infatti un protocollo di assistenza infermieristica basato sull’applicazione sistematica del problem solving method: un protocollo preciso (diagnosi e pianificazione) guida l’interazione professionale fra infermiere e la persona assistita. A lato di questa procedura il processo di assistenza infermieristica riconosce però anche un versante relazionale, spesso a torto detto umanistico riferendosi alla soggettività dei protagonisti interagenti: il professionista e il beneficiario dell’assistenza intesi nella loro globalità bio-fisiologica, psicologica e socio culturale. Nel pensiero infermieristico il significato della parola relazione viene però in genere tradotto come corrispondenza continua infermiere-paziente, basata sulle dimensioni personali del bisogno di assistenza infermieristica e caratterizzata da un modo di procedere dialogico e personalizzato centrato però sugli aspetti assistenziali, in cui dall’incontro degli interlocutori si determinerebbe la natura delle cure da fornire ed i mezzi con cui metterle in opera (Colliere, 1992; Motta, 2000). Nell’orientamento infermieristico viene affermata dunque la presenza di una relazione. Ma di che relazione si tratta? Quali sono le capacità necessarie per avere una buona relazione? E cosa si intende per “bisogni personali”? Innanzitutto occorre stabilire cosa sia la buona relazione. La buona o cattiva relazione è il prodotto della modalità con cui l’operatore entra comunque in interazione con il proprio paziente ed è modulata essenzialmente dalle capacità che la sua struttura, consapevole o no, mette in campo. DISEGNO DELLA LA RICERCA – 1° STUDIO Obiettivo del primo studio della presente ricerca, è un’osservazione delle capacità relazionali rilevabili nel rapporto infermiere/paziente, rapporto che si presume essere un caring. Si è voluto fissare l’attenzione principalmente su quelle dimensioni che possono costituire le capacità relazionali dell’infermiere. Questo basandoci anche su un confronto con le aspettative di relazione del paziente e cercando di esplorare quali collegamenti vi siano tra le une e le altre. La relazione e soprattutto la buona relazione non la si può stabilire con la buona volontà, né con la cosiddetta sensibilità umana, ma necessita di capacità che non tutti hanno e che per essere acquisite necessitano di un tipo di formazione che incida sulle strutture profonde della personalità. E’ possibile ipotizzare che la personalità e le sue dimensioni siano il contenitore e gli elementi di base sui quali fare crescere e sviluppare capacità relazionali mature. Le dimensioni di personalità risultano quindi lo snodo principale da cui la ricerca può produrre i suoi risultati e da cui si è orientata per individuare gli strumenti di misura. La motivazione della nostra scelta dello strumento è da ricercare quindi nel tentativo di esplorare l’incidenza delle dimensioni e sottodimensioni di personalità. Tra queste si è ritenuto importante il costrutto dell’Alessitimia, caratteristico nel possesso e quindi nell’utilizzo, più o meno adeguato, di capacità relazionali nel processo di caring,

Does improvisation lead to outcome deviation? A conceptual framework of improvisation, its antecedents and outcome deviation

Management and organization literature has extensively noticed the crucial role that improvisation assumes in organizations, both as a learning process (Miner, Bassoff & Moorman, 2001), a creative process (Fisher & Amabile, 2008), a capability (Vera & Crossan, 2005), and a personal disposition (Hmielesky & Corbett, 2006; 2008). My dissertation aims to contribute to the existing literature on improvisation, addressing two general research questions: 1) How does improvisation unfold at an individual level? 2) What are the potential antecedents and consequences of individual proclivity to improvise? This dissertation is based on a mixed methodology that allowed me to deal with these two general research questions and enabled a constant interaction between the theoretical framework and the empirical results. The selected empirical field is haute cuisine and the respondents are the executive chefs of the restaurants awarded by Michelin Guide in 2010 in Italy. The qualitative section of the dissertation is based on the analysis of 26 inductive case studies and offers a multifaceted contribution. First, I describe how improvisation works both as a learning and creative process. Second, I introduce a new categorization of individual improvisational scenarios (demanded creative improvisation, problem solving improvisation, and pure creative improvisation). Third, I describe the differences between improvisation and other creative processes detected in the field (experimentation, brainstorming, trial and error through analytical procedure, trial and error, and imagination). The quantitative inquiry is founded on a Structural Equation Model, which allowed me to test simultaneously the relationships between proclivity to improvise and its antecedents and consequences. In particular, using a newly developed scale to measure individual proclivity to improvise, I test the positive influence of industry experience, self-efficacy, and age on proclivity to improvise and the negative impact of proclivity to improvise on outcome deviation. Theoretical contributions and practical implications of the results are discussed.

Alterazioni del metabolismo osseo e fratture vertebrali dopo trapianto di rene

Introduction:Persistent Hyperparathyroidism after transplantation (HPT),bone disease and vertebral fractures are an important clinical problem in renal transplant patients. Several factors such as renal osteodystrophy, immunosuppressive therapy, deficit/insufficiency Vitamin D may contribute to that.In literature are described different percentages of HPT, vertebral fractures and Osteoporosis/Osteopenia that may be due to the different therapy and to the different employ of steroid. We analyzed 90 patients who received a renal graft between 2005 e 2010. Patients and Methods: 44 male and 46 female. Average age 52,2± 10,1 years, follow-up 31,3±16,6 months, time on dialysis 37±29,6 months. Patients who had creatinine level greater than 2,5 mg/dl were excluded. Immunosuppressive therapy was based on basiliximab, steroids (1.6 to 2 mg/kg/day progressively reduced to 5 mg/day after 45 days from the transplantation) in all patients + calcineurin inhibitor+ mycophenolate mophetil/mycophenolic acid in 88,8% of patients or Everolimus± calcineurin inhibitor in the others. Patients were studied with X-ray of the spine, dual-energy-X-ray, PTH, 25(OH)VitD. Results: 41,1% had HPT; 41,1% had osteopenia at femoral neck and 36,7% at vertebral column; 16,7% had osteoporosis at femoral neck and 15,6% at vertebral column. 10 patients (11%) had vertebral fractures. Patients with normal bone mineral density, compared to those with osteoporosis/osteopenia, are more younger (average age 46,4±11,7 years vs 54.3±8,6); they have spent less time on dialysis (26,5±14,8 months vs 40,7±32,6) and they have values of 25(OH)VitD higher (22,1±7,6 ng/ml vs 17,8±8,5). Patients with vertebral fractures have values of 25(OH)VitD lowest (14,1±6,4 ng/ml vs 19,7±8,5) and they had transplant since more time (29,1±16,2 vs 48,1±8,7 months). There is a significant correlation between HPT and PTH pre transplantation; HPT and levels of VitD (p<0,05) Conclusion: Prevention of Bone disease and vertebral fractures after renal transplant includes: a)treatment before transplantation b)supplementation of vitamin D with cholecalciferol or calcidiol c)shorten the dialysis time.

Crystal Engineering of bright luminescent copper iodide clusters with phosphorus and nitrogen-based ligands

Copper(I) halide clusters are recently considered as good candidate for optoelectronic devices such as OLEDs . Although the copper halide clusters, in particular copper iodide, are very well known since the beginning of the 20th century, only in the late ‘70s the interest on these compounds grew dramatically due their particular photophysical behaviour. These complexes are characterized by a dual triplet emission bands, named Cluster Centred (3CC) and Halogen-to-Ligand charge transfer (3XLCT), the intensities of which are strictly related with the temperature. The CC transition, due to the presence of a metallophylic interactions, is prevalent at ambient temperature while the XLCT transition, located preferentially on the ligand part, became more prominent at low temperature. Since these pioneering works, it was easy to understand the photophysical properties of this compounds became more interesting in solid-state respect to solution with an improvement in emission efficiency. In this work we aim to characterize in SS organocopper(I)iodide compounds to valuate the correlation between the molecular crystal structure and the photophysical properties. It is also considered to hike new strategies to synthesize CuI complexes from the wet reactions to the more green solvent free methods. The advantages in using these strategies are evident but, obtain a single crystal suitable for SCXRD analysis from these batches is quite impossible. The structure solution still remains the key point in this research so we tackle this problem solving the structure by X-ray powder diffraction data. When the sample was fully characterized we moved to design and development of the associated OLED-device. Since copper iodide complexes are often insoluble in organic solvents, the high vacuum deposition technique is preferred. A new non-conventional deposition process have also been proposed to avoid the low complex stability in this practice with an in-situ complex formation in a layer-by layer deposition route.